The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|RIVER OAKS HOSPITAL||1525 RIVER OAKS WEST HARAHAN, LA 70123||Feb. 24, 2012|
|VIOLATION: MEDICAL STAFF BYLAWS||Tag No: A0353|
|Based on record review and interview the hospital failed to enforce its bylaws. The medical staff did not implement its rules and regulations for suspension and disciplinary action of physicians who failed to complete medical records within 30 days after discharge. Findings:
Review of the Medical Staff Rules and Regulations revealed in part,"....On the thirtieth (30th) day after discharge, if the record is incomplete, the Medical Director, the Chief Executive officer, and the Chairman of the Medical Executive Committee will be notified to consider suspension of privileges or other appropriate disciplinary action. Suspension of clinical privileges will usually apply to future cases only. When privileges are suspended, the practitioner must complete all incomplete records before his/her privileges will be reinstated. A record is not complete until all material has been dictated, transcribed, and signed...".
Review of the Physician Delinquency rate for January 2012 revealed the total rate was 39% and the delinquent rate for the year 2011 was 42%.
Review of the Physician Delinquency rate per physician revealed:
S 8 MD had 6 charts over 30 days delinquent, 1 chart over 60 days delinquent, and 1 chart over 90 days delinquent.
S 19 MD had 7 charts over 30 days delinquent, 6 charts over 60 days delinquent, and 4 charts over 90 days delinquent.
S 40 MD had 2 charts over 30 days delinquent and 4 charts over 90 days delinquent.
S 41 MD had 1 chart over 30 days delinquent and 2 charts over 90 days delinquent.
S 39 MD had 1 chart over 30 days delinquent.
S 38 MD had 1 chart over 234 days delinquent.
An interview was conducted with S30 RHIA (Registered Health Information Administrator) on 02/24/12 at 9:25 a.m. She reported that the delinquency rate for medical records was 39% for January. She reported the system in place to notify the doctors of delinquent charts was to e-mail them once a week and "cc" S1 Administrator and S18 Medical Director. S30 stated she had been at the hospital about 4 years, and none of the physicians' privileges had been suspended for delinquent medical records.
An interview was conducted with S18 MD on 02/27/12 at 2 p.m. He stated he was the Medical Director of the hospital, and once a month in the Medical Executive Committee the delinquent rate per physician is presented to him. He further reported he speaks to the physicians and reminds them about their delinquent records. He also stated there was no disciplinary actions or suspension of privileges related to delinquent records, because he did not see the need for it.
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|Based on observations and interview the hospital failed to maintain a safe environment as evidenced by: 1) failing to ensure chemicals on the Children/Adolescent's unit were stored in a closet that was locked at all times; 2) allowing a broken, hard plastic lid to a linen cart with jagged, hard, pointed, sharp edges to be accessible to the patients utilizing the dayroom of the Children/Adolescent's Unit; 3) failing to maintain window frames and jams resulting in flaking and peeling paint; 4) failing to inspect air-conditioning vents resulting in paper and rags being inserted preventing air flow. Findings:
1) Failing to ensure chemicals on the Children/Adolescent's unit stored in a secured area were locked at all times:
Environmental observations were made on 02/22/12 at 10:50 a.m. with RN S28 Nurse Manager of the Child/Adolescent Unit, S33 Maintenance, and RN S34 Risk Manager. While on the Children/Adolescent Unit, a room labeled "Environmental Services" that contained eye wash equipment and chemicals was found to be unlocked and unsupervised at the time. The following chemicals were found on the bottom shelf of an open cabinet in the room: 2 containers of urine odor eliminator, 1 can of oven cleaner, 3 spray cans of insect killer, 1 gallon of disinfectant, 1 gallon of Febreze, and 1 gallon of floor cleaner.
On 02/22/12 the total census on the children's/adolescent unit was 13. There were (1) 8 year old, (1)12 year old, (1) 13 year old, (2) 14 year olds, (3)15 year olds, (1) 16 year old, and (4) 17 year olds residing on the children/adolescent unit.
An interview was conducted with S33 Maintenance on 02/22/12 at 10:50 a.m. He reported the door was to be locked at all times since there were chemicals in the room.
2) Allowing a broken hard plastic lid to a linen cart with jagged, hard, pointed, sharp edges to be accessible to the patients utilizing the dayroom of the Children/Adolescent's Unit:
Observation on 02/22/12 at 10:50 a.m. of the common area/dayroom revealed a dirty linen cart with a hard white plastic lid. Further observation revealed the lid had numerous pieces broken leaving the remainder of the lid with jagged, hard, pointed sharp edges. The finding was confirmed with S33 Maintenance.
3) Failing to maintain window frames and jams resulting in flaking and peeling paint:
Observation on 02/22/12 at at 11:00am of Room "a" revealed the window sill was rusted and flaking. Further review revealed the paint surrounding the window was bubbled and in some places was also flaking. The window pane had a deep approximately seven inch scratch which was almost completely through the thickness of the window pane.
In a face-to-face interview on 02/22/12 at 11:00am, S33 Maintenance Director indicated he performed monthly inspections of the environment; however windows are not part of the check.
4) Failing to inspect air-conditioning vents resulting in paper and rags being inserted preventing air flow:
On 02/22/12 at 11:40 a.m., observation on the Dual Diagnoses Unit revealed paper, cardboard and/or washcloths had been placed behind the plastic vent covers of the air conditioner unit preventing the flow of air. S33 Maintenance verified that patients slide things under the vent cover to block the air.
|VIOLATION: PATIENT SAFETY||Tag No: A0286|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview the hospital failed to ensure adverse patient events were documented and their cause analyzed for 3 of 24 sampled patients (#3, #6, #14). Findings:
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on [DATE] with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.
Review of Patient #3's "Multidisciplinary Progress Notes" revealed the following entry on 11/10/11 at 11:00pm by Psychiatric Counselor (PC) S31: "...Pt (patient) became upset when sent to bed early for cursing at peers. Pt wrapped a shirt around his neck & (and) said "I want to kill myself". RN notified Psychiatrist S8 & pt was placed on SVC (strict visual contact). (1) Staff provided support, guidance, & encouragement. (o) Pt not compliant (with) unit rules & structure. Pt needs redirection from staff. (P) continue to monitor & follow tx (treatment) plan". Further review revealed no documented evidence of an assessment by the RN of the patient's change in condition that included a suicide attempt. Review of the "Patient Monitor Record" documented by PC S31 and dated 11/10/11 revealed Patient #3 was asleep in Module C (children's unit) at 11:00pm.
Review of the hospital's incident report log revealed no documented evidence that an incident report had been completed in relation to Patient #3's suicide attempt and suicide threat.
In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 indicated Patient #3 should have been assessed by the RN on 11/10/11 when she notified Psychiatrist S8 of the above report from PC S31. S28 further indicated an incident report should have been completed by the RN. S28 further indicated PC S31 documented her note for the entire shift at 11:00pm, and there was not the specific time that the event with Patient #3 had occurred, which resulted in the observation record and the progress notes information not matching.
Review of Patient #3's "Progress Notes" dated 11/12/11 at 10:50 (no documented evidence whether it was am or pm) revealed documentation by PC S42 of "...He began attention seeking and pulling a towel around his neck. He started cursing and disrespecting staff...". Further review revealed no documented evidence that this was reported to the RN, and there was no documented evidence of a RN's assessment of Patient #3's suicide attempt. Review of Patient #3's "Patient Monitor Record" dated 11/12/11 revealed from 10:45am through 11:00am, Patient #3 was cooperative in Module C, and from 10:45pm through 11:00pm he was sleeping in the quiet room.
Review of the hospital's incident report log revealed no documented evidence that an incident report had been completed.
In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 indicated Patient #3 should have been assessed by the RN, and an incident report was required to be completed when patients made suicide attempts or threats.
In a face-to-face interview on 02/27/12 at 11:50am, RN Manager of the Child/Adolescent Unit S28 indicated the RN should document an assessment of the patient behaviors that warranted the need for prn medication.
In a face-to-face interview on 02/27/12 at 2:20pm, RN Risk Manager S34 indicated incident reports were to be reviewed by the supervisor and signed on the day the report was written, and she (S34) was to review and sign the report by the following day.
Patient #6 was an [AGE] year old boy admitted on [DATE] by Coroner's Emergency Certificate for hearing voices telling him to kill his school mates and himself. He attempted to put his head through a glass door because the voice told him to do it.
Review of the Progress Notes dated 12/02/11 at 9:20 p.m. revealed, "Pt (patient) became agitated, banging on walls, cursing, and tying his sheets around his neck. Pt made verbal threats to kill staff".
Review of the Incident and Accident reports for December 2011 revealed no documented evidence of an incident and accident report related to the patient attempting to tie sheets around his neck.
An interview was conducted with S 28 Nurse Manager on 02/27/12 at 11:10 a.m. She reported that an incident report should had been filled out related to the patient attempting to tie a sheet around his neck on the unit.
Review of Patient #14's medical record revealed he was admitted on [DATE] with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.
Review of Patient #14's "Multidisciplinary Progress Notes" dated 01/29/12 revealed an entry at 2:30pm by PC S36 of "...being physically aggressive punching a male child on the face over a movie. Pt was stopped by a female PC & was put in his room by other nursing staff who came to assist. Doctor was called by nurse & she told PCs that if pt stays in his room & he is able to calm himself down he will be okay no shot but a Vistaril by mouth... pt was put on early bedtime & no privileges. Monitor pt behavior encourage pt to follow his treatment plan...". Further review revealed no documented evidence of an assessment of Patient #14 by a RN and the report of the RN's phone call to the physician.
Review of the hospital's incident report log revealed no documented evidence that an incident report was completed related to Patient #14 striking another patient in the face.
In a face-to-face interview on 02/27/12 at 11:05am, PC S36 indicated she reported that Patient #14 had struck another peer in the face on 01/29/12 to the charge nurse, but she doesn't remember which nurse she told. S36 further indicated that she didn't know if an incident report had been completed at the time of the incident.
Review of Patient #14's "Multidisciplinary Progress Notes" dated 02/02/12 revealed a shift entry by PC S20 of "...appeared to have a limited affect. He could not participate in the activities & group because his behavior was out of control. He stated that he will do what he want. x 2 in the quiet room for his inappropriate behaviors...". Further review revealed no documented evidence that a RN assessed Patient #14's behaviors when he was "out of control" that warranted him to be placed in the quiet room twice by PC S20.
In a face-to-face interview on 02/27/12 at 9:02am, PC S20 indicated she placed a child in the seclusion room and left the door open when she documents that they are in the quiet room. S20 further indicated she kept the patient from exiting the room until they've "done their little time out". S20 further indicated she decides when the patient can come out of the seclusion/quiet room. When asked if she's familiar with the seclusion policy, S20 indicated that she was and reviewed it every 2 to 3 weeks. After being told that the hospital policy considered it to be seclusion when a patient was not allowed to leave a room, S20 reconfirmed that she kept patients from leaving the seclusion room when she placed them there for time-out until she determined that the patient could leave.
Review of Patient #14's "Reassessment/Progress Note dated 02/15/12 revealed documentation written across the front of the page with no documented evidence of the date, time, and name and title of the person who made the notation. Further review revealed the documentation included "Vistaril 25 mg p.o. (by mouth) at 4PM - agitated angry hostile threatening". Review of the PRN MAR revealed Vistaril 25 mg was given by mouth on 02/15/12 at 10:00pm. Review of the "Multidisciplinary Progress Notes" dated 02/15/12 revealed no documented evidence of an assessment by the RN of the behaviors exhibited by Patient #14 that warranted the need for prn medication at 4:00pm and 10:00pm.
In a face-to-face interview on 02/27/12 at 11:15am with RN Manager of the Child/Adolescent Unit S28 and RN Manager S11 present, S28 indicated an incident report should have been completed if the other patient was injured (relating to the above incident of 01/29/12). S11 indicated an incident report needed to be completed at the time even if the other patient was not injured. S28 indicated the RN should have performed and documented an assessment of Patient #14's behaviors. RN Manager S11 confirmed that an incident report had not been completed when Patient #14 struck another patient in the face on 01/29/12.
Review of the hospital policy titled "Healthcare Peer Review (HPR) Occurrence Reporting System", reviewed 08/11, revised 05/05, and contained in the policy manual submitted by Administrator S1 as current, revealed, in part, "...Occurrence (Incident Type): that which is not consistent with the routine care of a patient and/or the desired operations of the facility. ...Serious Injuries/Events constitute any of the following outcomes as a result of healthcare intervention but may not be limited to this list: ...Suicidal gestures or attempt, Injury/Physical harm to patients, staff or third parties... Violence...". Further review revealed the incident report was to be completed at the time of the event, signed by the individual preparing the report, reviewed by the charge nurse on duty at the time of the event for completeness and to assure the medical record documentation was appropriate and appropriate actions/interventions had been taken.